None Endovascular Management of IVC Injuries Adam Oskowitz M.D., - - PowerPoint PPT Presentation

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Endovascular Management of IVC Injuries

4/7/2017

Adam Oskowitz M.D., Ph.D. Assistant Professor of Surgery Division of Vascular & Endovascular Surgery

Disclosures

None

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Overview

• Challenges associated with IVC injuries
• Approach to treatment
• Endovascular options
• Cases

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Traumatic IVC Injuries

Mortality rate of patients that reach the hospital between 20% and 57%1 Injuries often made worse with surgical dissection The two most important factors for postoperative survival 3

• Hemodynamic condition on arrival
• Anatomic location of the injury

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1: Buckman RF et al. Injuries of the inferior vena cava. Surg Clin North Am. 2001;81:1431- 1447. 2: Huerta S et al. Predictors of mortality and management of patients with traumatic inferior vena cava injuries. Am Surg. 2006;72:290-296.

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Anatomic Considerations

(1) Infrarenal: 23% Mortality (2) Suprarenal: 75% Mortality (3) Retrohepatic: 66% Mortality

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Iatrogenic IVC Injuries

Rare Events Study looking at 231 attempts at filter retrieval over 10 years1

• Only 2 IVC injuries resulting in bleeding

‒ Both were treated with venoplasty alone ‒ Both occurred with advanced retrieval techniques

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Endovascular Treatment

Management goals of patients with IVC injuries1

• Minimize duration of shock
• Rapid control of active hemorrhage

The main advantages of the endovascular approach 2

• Speed
• Remote access
• Minimal additional trauma

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1: Huerta S, Bui TD, Nguyen TH, et al. Predictors of mortality and management of patients with traumatic inferior vena cava injuries. Am

• Surg. 2006;72:290-296.

2: Piffaretti G et al. Traumatic IVC Injury and Repair: The Endovascular

• Alternative. Endovascular Today. Nov 2013

Diagnosis

CT

• Active extravasation
• Hematoma
• Defined contrast gradient in IVC can signify an AVF

Venography

• Often difficult to visualize actually defect

IVUS

• Often more useful than venography

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Question

• A. Injury at the level of the renal veins
• B. Injury at the level of the hepatic veins
• C. Hemodynamic instability
• D. IVC filter in place that can NOT be removed
• E. All of the above

F. None of the above

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Which of the following represents an absolute contraindication to endovascular repair of an IVC Injury

3% 16% 28% 19% 9% 25%

Minimally Invasive Treatment Options

Medical Therapy Venoplasty

• Restoring favorable pressure dynamics can result in injury

resolution Placement of a Covered Stent

• Thoracic endograft
• Aortic cuff
• NO off the shelf venous specific devices available

Fenestrated Grafts

• Case report for retro-hepatic injuries

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Case One

28 year old man presenting after a motorcycle collision

• Arrived with stable vital signs
• Mild abdominal and flank pain
• CT scan identified IVC injury

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Two week follow-up

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Case 2

19 year old female pedestrian vs auto Multiple traumatic injuries including grade 4 liver laceration Head trauma Fluid responsive hemodynamic changes Suprahepatic IVC dissection and pseudoaneurysm identified on CT

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2 weeks later

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Case 3 Endovascular Management

IVC filter retrieval Advanced methods employed

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Endovascular Management

After filter manipulated BP suddenly dropped to 54/30

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Endovascular Management

Cava was not in continuity Transfemoral and transjugular balloon control achieved Wire from above snared from below Attempted Aortic cuff x 2 Ultimately repaired with 10cm thoracic endograft

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Available device options

No large diameter covered stents FDA approved for venous use Aortic Cuffs

• Available in 3.3 cm length and longer

Thoracic Devices

• Three major manufacturers make endografts that are ~10cm in

length

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Case 4

52 y/o with multiple prior abdominal surgeries undergoing routine lap cholecystecomy.

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Case 4

Massive Intra-op bleeding IVC repaired Nephrectomy Significant bloody output from intrabdominal drain on POD 2

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Fenestrated Repair

62 y/o man identified to have retro-hepatic caval injury after traffic accident Hemodynamically Unstable on Hospital Day 2 Fenestrated Repair attempted

• Graft modified on back table
• Deployed from below
• Hepatic veins marked with wires from above
• Completed in 2002!

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Question

• A. Injury at the level of the renal veins
• B. Injury at the level of the hepatic veins
• C. Hemodynamic instability
• D. IVC filter in place that can NOT be removed
• E. All of the above

F. None of the above Which of the following is an absolute contraindication to endovascular repair of an IVC Injury

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